Coverage Amount:     Height: 5'00" 5'01" 5'02" 5'03" 5'04" 5'05" 5'06" 5'07" 5'08" 5'09" 5'10" 5'11" 6'00" 6'01" 6'02" 6'03" 6'04"     Weight:    lbs.     Gender: Male Female   Date of birth: January February March April May June July August September October November December   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30   1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929

Please answer the following questions to help us better estimate your premium. Actual premiums will vary based on the results of our underwriting process. This is not an application for insurance and will not be used as part of the underwriting process.

Lifestyle profile Have you ever been convicted of a DWI (Driving While Intoxicated) or DUI (Driving Under the Influence)? No Yes- Within the last 3 years Yes- Within the last 5 Years Yes- Within the last 7 Years Yes- Over 7 years ago   Have you had more than two moving violations in the last two years? No Yes   Have you ever had a problem with or been treated for drug or alcohol abuse? No Yes- Within the last 5 Years Yes- Within the last 7 Years Yes- Over 7 years ago   When was the last time you used tobacco or nicotine products? Never Used Used in last 5 years Used in last 3 years Used in last year Current User   Do you work in a hazardous occupation? No Yes   Do you engage in any hazardous activities or sports? No Yes   Do you currently fly or intend to fly as a private pilot? No Yes

Medical history Have you ever been treated for or been told that you have high cholesterol? No Yes   Have you ever been treated for or been told that you have high blood pressure? No Yes

Indicate each medical condition that applies to or has applied to you: Asthma Anxiety Anemia Allergies Sleep Apnea Hypothyroid Reflux Epilepsy Chronic bronchitis Emphysema Gastric/peptic ulcer Hypertension Depression (last two years) Mental illness (treatment in last two years) Diabetes Cancer Heart Disease Check this box if you have family history of cardiovascular deaths or multiple cancer deaths prior to age 60 in parents or siblings.